AFTER JUDY JEAN Caquias died in Rikers Island custody last year, her youngest sister received a box from her old apartment with all of her personal belongings. Her whole life distilled into a pile of odds and ends: pictures of family, old papers from school, an iron-on patch of a woman with a rainbow flag flying. Yankees memorabilia, an Obama sticker, a political flier: “Demand housing for the homeless.” A program for a community play she’d been cast in, and on the cover, a picture of her as a sad clown holding an American flag. And photos of herself: a grainy selfie she took in her bedroom wearing a gray tank top and gold chain, with close cut gray hair and reading glasses. Another where she’s a little thinner, in a white baseball cap and gray hoodie, eyebrows raised and mouth slightly open as if she’s about to say something.

On May 6 of last year, Caquias — who everyone knew as Jackie — was incarcerated at Rikers on a years-old warrant for having missed drug court dates. She was a tough lady at 61, according to the defense lawyer in her criminal case. But she had a history of liver disease, including a bout of Hep C, and in her 20s and 30s she had been addicted to heroin, which can also do liver damage. Jackie had done time before on drug-related charges — but that was long ago. “She was very frightened of spending time in jail after all that time out,” her former lawyer Ilissa Brownstein says.

On Jackie’s second day at the Rose M. Singer Center, the island’s only women’s facility, the medical clinic ran lab tests that showed Jackie’s liver was severely stressed. Blood work two weeks later showed the same. Yet the doctors at Rikers didn’t send Jackie to a gastroenterologist for a liver exam. Instead, they prescribed her Tylenol 3 and iron, both dangerous for people with liver problems. The Tylenol 3 was discontinued after a week, but even after medical staff ordered the iron be stopped, the pharmacy continued dispensing it. Less than a month after Jackie arrived at Rose M. Singer, her system began to fail. She grew disoriented and delusional, and began vomiting so severely that blood and bodily tissue came up — all signs of acute liver failure. On June 25, 2014, after spending weeks in Elmhurst Hospital comatose and hooked up to machines, Jackie died. This according to a proposed amended notice of claim for a lawsuit to be filed this summer by her sister Daria Widing, and an analysis of health records by the medical expert hired for the case. The lawsuit, which will seek $20 million in damages, will charge that negligence by the City of New York contributed to Jackie’s death.

New York City’s chief medical examiner said Jackie’s death was caused by upper gastrointestinal hemorrhage and cirrhosis due to Hepatitis C and chronic substance abuse, according to the medical expert. The New York State Commission of Correction, which conducts inmate mortality reviews, determined that Jackie’s cause of death was natural, and the city’s Department of Health and Mental Hygiene (DOHMH), in charge of overseeing Rikers medical care, reviewed Jackie’s case and closed it shortly after her death.

Both DOHMH and Corizon, the private company that runs medical services at Rikers, say that privacy law prohibits them from commenting on the medical care of individuals. Corizon says it is “deeply saddened by any death.”

I asked several former Rose M. Singer inmates if they had known Jackie. When I asked Namala Conteh, there was silence on the line. Then the memory filtered back: “Oh my god, the one that passed away? Oh my — you just reopened my wound again. The crazy thing is — I — I — mmmmmm, fuck. It’s crazy. That — Oh my god.”

Conteh was there at the clinic when Jackie was finally taken in. “They were so neglectful,” she says of the staff. “They had that blood all over their hands.”

JACKIE’S DEATH APPEARS to fit a pattern; a series of health care-related deaths alongside the never-ending reports of brutality in the Rikers men’s jails have dominated headlines in recent months. Last year, the AP reported that poor medical care at Rikers had helped precipitate at least 15 inmate deaths over the past five years. After medical staff failed to treat a 59-year-old inmate for constipation, he died of complications from an infected bowel. Another man went into a diabetic coma and died within two days of being incarcerated. According to a complaint filed by his family, a 19-year-old boy who complained of chest pain for seven months was never given an X-ray and died in 2013 from a tear in his aorta. The New York Times recently detailed another death, that of Bradley Ballard, an inmate with schizophrenia and diabetes who died after being locked in his cell for six days without medication or running water.

But “women prisoners often get overlooked,” says Amy Fettig, a senior counsel at the ACLU’s National Prison Project. The island’s women’s jail, known as Rosie, is home to about 600 of the 11,000 inmates at Rikers. “In some facilities you might not see beat-ups, but you’ll see the violence of not receiving appropriate health care,” she says. Medical records, inmate complaint data, and interviews with current and former inmates bear this out.

Pharmaceutical errors like the ones that may have contributed to Jackie’s death aren’t uncommon at Rosie. Between July of last year and April 2015, the Legal Aid Society — the largest provider of legal services to the city’s poor — received complaints from 17 Rosie inmates who said their prescriptions had gone unfilled or their meds were discontinued for no apparent reason. Two Rosie inmates The Intercept spoke with described recent instances in which they received the wrong medication or the wrong dosage.

Last September, Kim Midyett went down to the clinic because she was feeling sweaty and shaky. According to medical records, her blood sugar had plummeted. Midyett told a doctor that earlier that morning, a nurse had injected her with 12 units of insulin instead of the prescribed six. That’s not a trivial error, says Dr. Josiah Rich, a prison health care expert at Brown University. “The wrong dose of insulin can kill you.”

Virdie Emmanuel, who landed on Rikers in January 2014, has dark circles under her eyes, a sweet smile and a grand larceny conviction. Emmanuel’s health problems began at age 10, when her appendix ruptured. By 20, she had Crohn’s disease and says she “basically lived at Mount Sinai [Hospital] for weeks at a time.” The diseases and disorders kept piling up. Now, on top of Crohn’s, the 41-year-old has rheumatoid arthritis, hypertension, fibromyalgia, morbid obesity, anemia, asthma, PTSD, anxiety and depression, according to medical records. By 2013, Emmanuel says she was buried in hundreds of thousands of dollars worth of medical bills. She was arrested for — and pleaded guilty to — charging $1.3 million worth of personal expenses to her employer’s account. Emmanuel says it was to pay off her medical debt.

Once in jail, her health began to deteriorate further. Emmanuel takes about a dozen pills a day to manage her conditions. Last winter, her prescription for Lyrica, a fibromyalgia drug, was allowed to lapse, causing her severe muscle pain and numbness. And she submitted complaints about receiving the wrong meds several times over the past year. In January, medical director Lisa Choleff admitted in a response to a complaint form Emmanuel had submitted that she had “received the wrong medication for several months, then when it was caught, medical did not prescribe it to her, yet pharmacy had been dispensing it to her.”

After an inmate death in 2010, the New York State Commission of Correction ordered Corizon, which is the largest private correctional health care provider in the country, to evaluate why patients’ medications were often discontinued after admission. And in 2011, after another death, the commission demanded the company fix problems with its dispensation of psychotropic meds and review its pharmacists’ professional qualifications.

Corizon says its employees “work hard to provide our patients with appropriate care — including providing all treatment and medication that is clinically indicated.” And yet the company — which services 345,000 inmates in 531 jails, prisons and detention facilities around the country — has built itself a reputation for cutting costsand putting patients’ lives at risk. Corizon was reportedly sued 660 times for malpractice between 2008 and 2013, and has been implicated in class action lawsuits filed by the ACLU and the Southern Poverty Law Center. The company says its “patient population is highly litigious,” and that the “existence of a suit is not necessarily indicative of quality of care or any wrongdoing.”

New York City attempted to prevent the company from cutting corners when it hired Corizon’s corporate predecessor, Prison Health Services, in 2000. The city’s cost-plus contract with the company keeps Corizon from skimping on lab tests or specialty care or prescriptions in order to jack up profits. And DOHMH provides heavy oversight of health care on the island.

But inmate medical care involves treating high volumes of very sick people in a grim and often dangerous setting, and attracting good staff can be hard for any jail health care operation. Since last fall, two Corizon staffers at Rikers have been arrested for smuggling contraband into the jail. In July 2010, a Rikers doctor was arrested for sexually abusing a female inmate. That same month, another doctor resigned over questions about the validity of his certification to provide medical care to inmates. And in 2000, before Corizon hired her, medical director Lisa Choleff had her license restricted for several years on a rare disciplinary action over charges of “gross negligence, gross incompetence and negligence, and incompetence on more than one occasion.” She notes in her public profile at the New York State Department of Health that the disciplinary action “has now been resolved.” She did not respond to a request for comment.

DOHMH notes that it conducts regular credentialing reviews of physicians and PAs. Corizon says its staff “have taken the same Hippocratic and nursing oaths … as those in hospitals and medical facilities across the country.”

The company emphasizes: “We consider it our mission to care for our patients as we would our own family.” But at a recent city council hearing, Corizon’s chief medical officer, Dr. Calvin Johnson, was at a loss when a council member asked what specific reforms the company had recommended to improve care at Rikers in the wake of the recent string of deaths. Despite rephrasing the question six times, the council member never got a direct answer.

A view of buildings at the Rikers Island penitentiary complex in New York on May 17, 2011. (Emmanuel Dunand/AFP/Getty)

AFP/Getty Images

TO GET TO RIKERS, you have to wind your way to the top of Queens and then cross a long low bridge over Flushing Bay, which circles the island to the south. As Jackie crossed the bridge, she probably saw planes lifting off from LaGuardia for another coast or country — rising over the wide bay, then over the mouth of the East River to the north of the island. She might have seen a diagonal of seagulls in the sky. She might have smelled the smell of the raw sewage overflow that empties into the bay after a rain before she headed toward the compound’s concentric fences and swirls of razor wire.

Jackie was arrested in Harlem last year while talking on the phone with her sister Daria Widing, waiting for a downtown bus. After a 2009 arrest for selling heroin, a judge had ordered Jackie to go to drug court, which required her to be free from painkillers. She was facing intense pain from an injured knee and back, and according to her former defense attorney, eventually decided to go back on her pain meds. A few months in, she started missing court dates and a warrant was issued. In May 2014, the police picked her up and Jackie was sentenced to jail.

Eighty-four percent of women incarcerated nationwide are locked up for a nonviolent crimes. Most are poor. A disproportionate number are black or Hispanic.

Jackie grew up in the Washington Projects in Spanish Harlem in a big Catholic family. She was a teenager in the 1960s, a 20-something in the 1970s, and she was gay when being gay was fringe. So she fell in where she belonged. She was a hippie and did hippie things. She traveled the country. She used drugs. She did time here and there, usually on drug-related charges. “She visited a great many states through their penal systems,” Widing laughs.

And she became an activist. Jackie joined the Young Lords, a Puerto Rican nationalist group that worked on police brutality, education, health care and tenants’ rights. In the late’70s, she and some friends launched a crisis intervention service for teens called HOTLINE Cares.

She was a heroin addict for a long time, but she was a “functioning addict,” Widing says. Jackie always managed to find odd jobs, working in social services, as a bike messenger, even as a production assistant. She did seasonal work on electoral campaigns for years. And she never let go of her causes. She fought for affordable housing, school study centers and drug rehab programs in her neighborhood. HOTLINE Cares ran for over 30 years and has been held up by the Justice Department as a model teen drug prevention program.

“I’m a stand-up bitch,” she was known to say.

It was the same with her friends and family and lovers. When a girlfriend wanted a Bowflex, Jackie bought it for her. If a friend’s baby needed a crib, Jackie would get it. She took on her older sister’s car payment for years. “She had a studio, like, my closet might be bigger, but everybody was welcome,” Widing says.

Jackie was only at Rosie for a few weeks, but she made tight friends fast. “I really had a issue with people’s sexuality,” Conteh says. “I was like, Jack, leave me alone. But then we kinda just became friends. That’s why I was like ughhhh when I heard that she passed. It was, like, really bad.”

TOWARD THE END of May 2014, Conteh and several other inmates at Rosie noticed that Jackie had stopped eating and kept nodding off. As the days passed she became disoriented and then delusional, attempting to lie down in other inmates’ beds and mistaking a pantry for the bathroom. “A couple of days she wasn’t eating, and then she started throwing up,” says Diana Mack, an inmate in Jackie’s unit. “But she didn’t have nothing in her stomach to throw up, so the bile came up, and then the blood came.” By June 1, according to the notice of claim, Jackie was throwing up blood and bodily tissue.

A guard immediately alerted the clinic, and two medical personnel arrived with a stretcher. But when an incoherent Jackie wouldn’t get on, the staffers left, according to the notice. They said she was refusing medical attention, despite her cellmates’ insistence that she was no longer capable of making rational decisions. Eventually, Tiffany James, known as Buddha — who had bonded with Jackie over their shared birthday — dressed Jackie and carried her down to the clinic with another inmate. When they arrived, a doctor took a look at Jackie and said, “You call this a medical emergency?”

“That’s people just not giving a shit,” Widing says.

Forty-five minutes later, EMS finally picked Jackie up and transported her to the ER. The Rikers clinic had told 911 operators that Jackie needed to be picked up because she was “emotionally disturbed” — not because she was having a medical emergency, according to the medical expert hired for the case. When she arrived at Elmhurst, lab tests confirmed she was in acute liver failure.

Corizon says that “in the case of an emergency, we call 911 immediately.”

NEW YORK CITY’S Department of Corrections has recently come under intense scrutiny over correction officers’ brutality toward inmates, but what the Justice Department has called a “deep-seated culture of violence” is also undercutting inmate health care. A March 2015 study by DOHMH officials found that medical staff throughout the New York City jail system often made decisions based on security priorities. Patients interviewed said they saw no separation between medical and correctional staff. “There is not DOC and medical,” Conteh agrees. “It’s medical-DOC.”

Legal Aid — which does not investigate each grievance — has received numerous inmate complaints of medical staff at Rikers dismissing patient complaints as malingering. A male inmate told the organization in January that after he fell and injured himself, a Corizon doctor told him to “Get the fuck up,” and “There’s nothing the fuck wrong with you.”

Legal Aid often receives complaints about Rikers correction officers blocking access to the clinic, and yet according to city council hearing testimony by Legal Aid’s John Boston, Corizon management has not set up a system to protect prisoners’ right to timely access to daily sick call.

Last summer, Alejandra Rodriguez, a former Rosie inmate with thick glasses and a faint lisp, says she slipped on a piece of soap in the shower and hit her head on the floor. Rodriguez, who went by Fat Baby, says she told the captain in her housing unit that she felt like she was going to throw up and needed medical attention. “The captain said that if I were in the street I would not ask to be going to a clinic, and she left,” Rodriguez wrote to me last year. (DOC says that “every complaint of denial of access is investigated and remediated if necessary.”)

The next day, guards permitted her to go to the clinic. But she wasn’t diagnosed with a concussion for another six days, according to her medical records, at which point she was deemed “neurologically unstable.”

ON SEPTEMBER 9, 1971, a thousand prisoners at the Attica Correctional Facility in upstate New York rioted and seized control of the prison in what became the bloodiest prison uprising in U.S. history. The riot stemmed from prisoners’ demands for decent living conditions, an end to brutality and better medical care. The Attica rebellion helped prompt a slew of prisoner lawsuits that culminated in a landmark 1976 United States Supreme Court ruling.Because inmates are not able to seek out medical care themselves, the court said, the failure to provide them with proper health care constitutes a violation of the 8th Amendment’s ban on cruel and unusual punishment.

Most inmates at Rikers are awaiting trial. Many others are in on short stays for minor crimes. That someone jailed so briefly would suffer unconstitutional medical care is all the more jarring. Conteh, for example, was arrested in October 2013 for criminal possession of stolen property. The 32-year-old says it was because she was waiting in the car for her friends who were robbing a clothing shop. When she was released last June, she says she “literally crawled” out of Rosie and spent months bedridden, undergoing physical therapy because of complications from neglectful treatment of a broken ankle sustained after an assault by a correction officer.

The incident took place in February 2014, when a fight broke out between an inmate and a guard just outside Conteh’s cell. When Conteh tried to pull the inmate away from the officer, another guard threw Conteh to the floor, lifted her up and slammed her back down again, according to a lawsuit Conteh filed against the city. (The city has denied all of her claims.) The following day, an X-ray showed she’d fractured her left distal tibia and fibula, but she waited three weeks to get a plaster cast put on at Elmhurst, which is run by the city. (She missed one appointment, 10 days after the ankle fractures, because of a court date.) It took two tries for doctors to fit the cast properly, and the break healed poorly, leaving painful scar tissue in her ankle and requiring her to undergo surgery after her release.

This past January, Emmanuel also fractured her left foot, and never received a splint or a boot. Instead, she got a wheelchair that was too small for her body, according to a complaint submitted by Legal Aid. X-rays in February and April showed the fracture was not healing. (Corizon says she “received appropriate care.”) Legal Aid has received at least three complaints in the past year from Rikers inmates who said the clinic wouldn’t give them a cast or a splint. A DOHMH spokesperson says that patients with urgent needs get immediate emergency care.

Legal Aid also gets frequent complaints from inmates about delays in getting specialty care at Elmhurst and Bellevue, the two hospitals that service Rikers. In July 2014, a Rosie inmate who asked to remain anonymous was arrested on charges of prostitution and failure to show up at court. At the time of her incarceration, the 32-year-old was pregnant and had a large and painful ovarian cyst pressing into the left side of her abdomen. She ended up waiting four months for an appointment at Elmhurst to have it removed. Meanwhile, she miscarried. “I woke up in my dorm in a pool of blood,” she says. Though the cyst was benign, “it sounds like that was a significant delay,” says Dr. Scott Allen, a prison health care expert at the University of California Riverside, who did not view medical records but was briefed on summaries of inmate cases.

In February 2014, shortly after her arrest on a drug possession charge, Diana Mack, 54, had a chest X-ray that revealed an unidentifiable mass in her right lung. Mack had to wait three months to get a CT scan at Elmhurst, and says she never received the results before she was released four months later in September. Mack only found out that the scan of her lung was inconclusive after The Intercept requested the results from Elmhurst. “Why they didn’t see to it that I got that information?” she wondered.

One reason for the delays in getting care at Elmhurst, a city official says, is that the hospital has too little space and staff to meet Rosie’s needs. And inmates often complain to Legal Aid that DOC, which is responsible for transporting inmates to their outside appointments, brings patients to their specialty clinic appointments too late, or not at all. Corizon says its “process is consistent with how you might schedule a specialty appointment in almost any health care setting.”

Several doctors The Intercept asked to weigh in on summaries of inmate cases contend that patients at public hospitals across the country face the same issues of access and delays. But that may be a false equivalence, Allen says: “They don’t have the liberty to seek alternative care themselves, do they?”

Changes could be coming soon to Rikers. In 2013, the city downgraded Corizon’s performance rating from “good” to “fair.” After the death of Bradley Ballard, a state review recommended against renewal of Corizon’s contract, which expires at the end of the year. And city council members are pushing the mayor’s office to turn inmate health care over to the city’s public Health and Hospitals Corporation, which runs hospitals like Elmhurst and Bellevue.

The reason New York City has kept Corizon around for so long despite the company’s many failings is that no one else has wanted to take over the contract. When the city put out a proposal request in 2000, Corizon’s corporate predecessor was the only entity with the proper capacity to bid. Since then, according to two former city officials familiar with the bidding process, no other provider with the infrastructure to handle such a huge system has expressed any interest in taking over care of inmates on Rikers Island.WIDING FOUND OUT that Jackie had been taken to the ER when she happened to call Rikers to ask for the address to send her sister a letter. The operator told her Jackie had been taken to Elmhurst. When Widing called the hospital and asked to speak to her sister, the doctor told her that wouldn’t be possible. “She’s in a coma,” she recalls him saying.

Widing wasn’t there on Jackie’s last day — she lives in Florida and was scheduled to visit her sister the following week. Another sister Anna had come by, and Jackie’s niece, and her Aunt Judith, who arranged her bedding and recited a prayer and rubbed her feet.

Jackie coded two or three times on the morning of June 25 — the digital line of her heartbeat falling flat on the monitor. She kept bleeding and bleeding and her organs began to fail. Widing asked the doctor what Jackie’s life would be like if they kept her alive. He said she’d been without oxygen to her brain for too long and her body was shutting down. “At this point we’re breathing for her,” he said. So Jackie’s family agreed to disconnect all the machines and let her go, Widing says. “That was around 9:40 that morning. By 2:45 she was gone.”

This article was reported in partnership with The Investigative Fund at The Nation Institute, with support from the Puffin Foundation.

Sheelagh McNeill contributed research to this report.

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